Orthopaedics Flashcards
What % of back pain is due to mechanical back pain?
85 - 90%
Causes of mechanical back pain
- trauma
- muscular / ligamentous pain
- fibrositic nodulosis
- postural back pain (sway back)
- lumbar spondylosis
- facet joint syndrome
- lumbar disc prolapse
- spinal and root canal stenosis
- spondylolisthesis
- disseminated idiopathic skeletal hyperostosis
- fibromyalgia
Red flags in back pain history
- Serious trauma / fall from height
- minor trauma in osteoporosis
- age < 20 or > 50 at onset
- history of cancer / drug abuse / HIV / immunosuppression / prolonged corticosteroids
- constitutional symptoms - fever, chills, weight loss
- pain worse when supine
- severe pain at night
- thoracic pain
- constant and progressive pain
- severe morning stiffness
- patient unable to walk / self care
- saddle anaesthesia
- recent onset problems with bladder and bowels
What are waddel’s signs used for
Used to indicate non-organic psychological component to chronic back pain
What are Waddel’s signs
- Superficial non-anatomical tenderness
- overreaction
- pain on axial loading
- pain on passive rotation
- straight leg raise test discrepancy between supine and standing
- non-dermatomal sensory loss
- give-way weakness
Red flags on back pain examination
- structural deformity
- severe / progressive neurological deficit
- anal sphincter laxity
- peri-anal / perineal laxity
- major motor weakness
Symptoms suggesting cauda equina syndrome
Bladder dysfunction (retention +/- overflow) Sphincter disturbance Saddle anaesthesia Lower limb weakness Gait disturbance
Investigation of back pain
Spinal x-ray - if neuro syx, 50yo, worse at night/morning, systemic syx MRI - better for neuro CT -better for bone Bone scan - for infection / malignancy FBC, ESR, CRP - for infection LFTS - Paget's disease, bony mets PSA - prostate ca CXR - lung ca USS - renal stones, pancreatitis, leaking AAA endoscopy - posterior ulcer
Risk factors for recurrent mechanical back pain
Female ^ age Job dissatisfaction Pre-existing widespread chronic pain Psychological distress - depression / anxiety
Types of trauma that may cause mechanical back pain
Lifting Sports Fall RTA occupation Housework Sudden jolts Gardening
What are fibrositic nodules
Tender nodule in a muscle. Usually buttock / along iliac crests
Causes unilateral or bilateral low back pain.
Radiates to buttock and posterior thigh.
In whom is postural back pain most common
Pregnancy
Obesity
Muscle weakness
What is sway back
Postural back pain
What disc changes occur in spondylosis
Changes in disc gel - breaks up, shrinks, loss of compliance
Surrounding fibrous zones develop circumferential fissures
Discs become thinner and less compliant
What is facet joint syndrome
Arthritic changes and inflammation of facet joints
May be secondary to spondylosis
Symptoms of facet joint syndrome
Lower back pain - worse on bending forward + on straightening from flexion.
Radiation to buttocks
Unilateral or bilateral
Management of facet joint syndrome
Diagnostic injection of LA into facet joint.
Then corticosteroid injection into joint
Physiotherapy
Weight loss
What happens in disc herniation (prolapse)
Herniation of the nucleus pulposus (gelatinous centre part) through the annulus fibrosus (fibrocartilaginous outer layer)
What is spondylolisthesis
Slipping of one vertebral disc forward over the lower one
In what age group is spondylolisthesis most common
Adolescents / young adults
What happens in disseminated (diffuse) idiopathic skeletal hyperostosis?
Bony overgrowths + ligamentous ossification
Characterised by flowing calcification over the anterolateral vertebrae
What is Forrestier’s disease
disseminated (diffuse) idiopathic skeletal hyperostosis
What is fibromyalgia
A syndrome of long-term widespread body pain - affects joints, muscles, tendons and soft tissues.
Linked to fatigue, sleep problems, depression, anxiety, headaches
What spinal fracture is more common in osteoporosis?
Vertebral crush fracture
What causes a widows stoop
Increased thoracic kyphosis due to multiple osteoporotic vertebral fractures
How do you diagnose osteoporotic crush fractures
X-ray - loss of anterior vertebral body height and wedging.
Tx of osteoporotic crush fractures
Bed rest and analgesia - until pain subsides
Gradual mobilisation
May need hospitalisation - IV bisphosphonates or SC calcitonin.
What do yellow flags signify
Psychological barriers to active rehabilitation and risks of chronicity.
Yellow flags in back pain include:
Belief pain and activity are harmful Sickness behaviours Social withdrawal Low / negative mood / anxiety Problems at work / job dissatisfaction Compensation / claims Lack of family support Inappropriate expectation of tx
What % of the general population have a bulging disc on MRI
Upto 79%
What % of people with back pain return to their GP within 3m
> 29%
Risk factors for osteoarthritis
>65yo Female (usually more severe - but prevalence = in both sexes) Genetic Obesity Joint injury Muscle weakness Meniscal damage
Radiological features of osteoarthritis
Joint space narrowing
Osteophyte formation
Bone cysts
Sclerosis
Features suggestive of osteoarthritis
Pain - exacerbated by activity, relieved by res
Stiffness - transient, after rest / in morning
Reduced movement
Swelling
Crepitus
Increased age
Common sites of osteoarthritis
Hands
Knees
Hips
Management of osteoarthritis
Weightloss Appropriate footwear Physiotherapy NSAIDS / opiates Effusion aspiration surgery - osteotomy / joint replacement
Location of Hebredens nodes
distal interphalangeal joints
In osteoarthritis
Location of Bouchards nodes
Proximal interphalangeal joints
In osteoarthritis
Risk factors for rheumatoid arthritis
Female:male 3:1
Age 40-60
Family history
Smoking
Common deformities in RA
Swan neck
Boutonnière
Z thumb
Ulnar deviation
Where is the olecranon bursa
Over the ulna at the posterior tip of the elbow
Near the surface. Therefore, often exposed to trauma.
Syx of olecranon bursitis
Focal swelling over tip of elbow +/- pain
Pain may be exacerbated by pressure
Onset may date from trauma - onset without trauma suggests infection.
Signs of olecranon bursitis
Well demarcated swelling Red Warm Skin may show contusion or abrasion. Movement decreased at end of flexion - due to pain.
What does elbow pain on passive or active movement suggest
Possible olecranon process fracture
DDX of olecranon bursitis
Fractured olecranon process Haemarthrosis Inflammatory arthropathy e.g RA Crystal arthropathy e.g. Gout Autoimmune disease Ehlers Danlos Syndrome Synovial cyst
Investigations for olecranon bursitis
FBC - WCC Uric acid levels CRP / ESR RF Plain x-ray if hx of trauma Aspiration of bursa
What are gout crystals made of
Monosodium urate crystals
What are pseudogout crystals made of
Calcium pyrophosphate
OR
Hydroxyapatite
Management of olecranon bursitis
RICE - rest, ice, compression, elevation
Antibiotics if septic
Aspiration
Steroid instillation
Possible complications of olecranon bursitis
Septicaemia
Osteomyelitis
Persistent pain
Causes of non-specific neck pain
Poor posture Neck strain Sports Occupation Anxiety and depression
Causes of neck pain
Posture, injuries etc RA, OA, Fibromyalgia, osteoarthritis Cervical spondylosis Cervical intervertebral disc prolapse Spinal stenosis Osteomyelitis Whiplash / trauma CV, Resp, upper GI problems
Rick factors for neck pain
Neck posture Arm posture Prolonged sitting Twisting / bending of the body Hand / arm vibration Excessive pillows Excessive concerns Issues of injury compensation Psychosocial problems
What is cervical radiculopathy
Compression or injury to a nerve root in the c- spine
Syx of cervical radiculopathy
Pain - unilateral neck, shoulder or arm
Motor dysfunction - weakness
Sensory deficit - altered sensation, paraesthesia
Altered tendon reflex
Red flags in neck pain
New syx 55yo
Weakness in >1 myotome
Intractable / increasing pain
Neurological syx - gait disturbance, clumsy/weak hands, loss of bladder/bowel syx
Malaise, fever, weight loss
Hx of inflammatory arthritis, cancer, TB, immunosuppression, HIV,
Lymphadenopathy
Hx of violent trauma / fall from a height
Dizziness / blackouts
DDX of neck pain
Disc prolapse
Tonsillitis
C-spine injury –> muscle strain, dislocation, fracture
Vertebral osteomyelitis
Cervical lymphadenopathy due to cancer
Eye disorders
Dystonia secondary to stroke, encephalitis etc
Dystonic reaction - antipsychotics, metoclopramide, cocaine
Pseudodystonia
Somatisation
What is tunnels test + what’s it for
Tap over median nerve at wrist
To reproduce syx in carpal tunnel.
What is phalens test + what’s it for
Hold the wrists palmar flexed together for 1 min
To reproduce syx in carpal tunnel
What are the LOAF muscles
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
What is supplied by the ulnar nerve
Hand muscles (except LOAF muscles) Sensation to ring and little finger
Syx of chronic ulnar lesions
Clawing of the hand
Do proximal or distal ulnar nerve lesions cause more marked clawing of the hand
Distal = more clawed
Which cancers metastasise to bone?
Lung Breast Thyroid Renal Prostate
What part of the rotator cuff is most commonly injured?
Spraspinatus
What is hypertrophic pulmonary osteoarthropathy?
Subperiosteal new bone formation in the long bones
Pain and painting of the anterior shin
Presentation of posterior dislocation of the shoulder
Painful shoulder
Most commonly occurs after a seizure
On examination the coracoid process may be prominent
What does a dinner fork deformity suggest?
Colles fracture
Presentational De Quervain’s tenosynovitis
Pain on wrist adduction and flexion
Radial side of wrist
What is an important side effect of bisphosphonates
Osteonecrosis of the jaw
Features of carpal tunnel syndrome
Lateral 3 1/2 fingers
Pain
Paraethesia
What does a prominent tender tibial tubercle suggest
Osgood-schlatter disease
Radiological features of rheumatoid arthritis
Loss of joint space
Subluxation of joints
Erosions
Soft tissue swelling
Radiological features of Paget’s disease
Local bone enlargement
lytic lesions with nearby sclerosis
Long bone bowing
Radiological features of ankylosing spondylitis
Syndesmophytes
Bamboo spine
X-ray appearance of Sunday speculation suggests….
Osteosarcoma
X-ray appearance of onion peel sign suggests….
Ewings sarcoma
What is perthes disease
self-limiting hip disorder
caused by ischaemia and necrosis of the femoral head.
avascular necrosis of the proximal femoral epiphysis.
Abnormal growth of the epiphysis results.
Eventual remodelling of regenerated bone.
Classical patient with perthes disease
4 - 8 year-old boy delayed skeletal maturity. Male to female ratio: 5:1 Rare in non-Caucasians. Increased incidence with family history, low birthweight, abnormal pregnancy/ delivery.
Presentation of perthes disease
all movements at the hip are limited. early phase - limited hip abduction, limited internal rotation antalgic gait Trendelenburg gait - seen late. No history of trauma.
Management of Perthes disease
Children 8yp - surgery + physio
What does SUFE stand for?
Slipped upper femoral epiphyses
Classical patient with SUFE
Adolescent - 10-17yo
Peak age = 13 years for boys. 11.5 years for girls.
left hip is more commonly affected than right
bilateral in 20-40%
3x more common in boys.
Risk factors for SUFE
Mechanical: local trauma, obesity. Inflammatory conditions: neglected septic arthritis. Hypothyroidism, hypopituitarism, growth hormone deficiency, pseudohypoparathyroidism. Previous radiation of the pelvis, chemotherapy, renal osteodystrophy-induced bone dysplasia.
Presentation of SUFE
Discomfort in hip, groin, medial thigh or knee during walking
pain accentuated by running, jumping, or pivoting.
Pre-slip: slight discomfort.
Acute: Severe pain - unable to walk / stand.
limp on the affected side,
external rotation of the leg.
Hip motion limited - esp internal rotation and abduction
Chronic: Mild symptoms - child able to walk with altered gait.
Symptoms of posterolateral intervertebral disc herniation
Acute onset back pain
Sciatica
Symptoms of spondylosis
Aching pain
Worth on activity and in the morning
Some restriction of spinal movement
No muscle spasm
Symptoms of spinal stenosis
Back and leg pain on standing and walking
Relieved by sitting or bending forward
What is discitis and who does it affect
Infection of the intervertebral disk
Occurs in young children
Symptoms of discitis
Severe pain
Refusal of movement
Impaired mobility
What does a palpable step on examination of the spine indicate
Spondylolisthesis
What is Potts disease
TB of the spine
Often results in abscess formation
Management of SUFE
Avoid moving or rotating the leg. Do not walk. analgesia Immediate orthopaedic referral. scheduled for surgery immediately. Surgical closure of the epiphysis - screws percutaneously.
Presentation of an anterior dislocation of the shoulder
Usually caused by a fall onto the outstretched hand or shoulder.
Severe shoulder pain
Unwillingness to move arm
Flattened shoulder contour
Humeral head palpable in infra-clavicular fossa
Most common type of shoulder dislocation
95% anterior
What nerve can an anterior shoulder dislocation damage
Axillary nerve
Weakness of deltoid
Regimental patch numbness
Most likely cause of severe pain on shoulder abduction >120 degrees
Suprasipinatus tendonitis
Presentation of a frozen shoulder (adhesive capsulitis)
Hx of minor trauma Middle aged Aching pain Restricted shoulder flexion, extension, rotation and abduction Spontaneous recovery over 12m
What is impingement syndrome (painful arc syndrome)
Pain on adduction between 60-120
Due to mechanical nipping of a tender structure between the acromion and greater tuberosity.
Can be due to incomplete tear of suprasipinatus tendon, chronic suprasipinatus tendonitis, subacromial bursitis
What 4 muscles make up the rotator cuff
Suprasipinatus
Infraspinatus
Subscapularis
Teres minor
Presentation of rotator cuff tear
Shoulder tip pain
Local tenderness at lateral margin of acromion process.
Inability to abduct the arm
Can hold arm in abduction if passively elevated to 90degrees + due to deltoid.
Once lowered below 90 - arm drops
Management of an intracapsular fractured neck of femur
Internal fixation with cannulated screw if undisplaced
Hemi-arthroplasty if displaced
What is the classification system for femoral neck fractures
Garden
Type 1 - stable fracture.
Type 2 - complete but non-displaced.
Type 3 - partially displaced but still has some contact between 2 fragments.
Type 4 - completely displaced + no contact between 2 fragments.
What are the 2 main types of hemi-arthroplasty
Cemented - Thompson’s
Non-cemented - Austin-Moore
Presentation of patellar fracture
Knee pain
Haemarthrosis
Inability to extend knee
Symptoms of transient synovitis
Most common cause of hip pain in prepubescent children Often follows viral infection Suffer onset hip pain Slight limp Reduced range of movement No pain at rest No systemic symptoms
What causes trigger finger
Thickening and constriction of the mouth of the tendon sheath. The tendon beComes swollen under the sheath.
Easy to flex the finger. But difficult to extend
